Document 443VzprkBOGQk5N3Dkm59eyyV

HEALTH + PAC HEALTH POLICY ADVISORY CENTER INSTITUTE FOR POLICY STUDIES Bulletin No. 6 Nov. - Dec. 1968 MEDICAL EMPIRES: WHO CONTROLS? L Medical research, teaching and specialized services empires, based primarily in seven loose medical school hospital - affiliation networks, are increasingly the centers of power in New York's medical establishment, with mammoth institu- tional control of the major medical resources in the City. Increasing amounts of public finance and authority are being concentrated in these medical empires for control over the planning and delivery of health services, as well as for biomedical research and education; for example, as follows: OE Lucratively subsidized affiliations for professional control of Municipal hospitals and health centers; effective pri- vate empire ownership of these public institutions is now being contemplated under new plans being drawn by the City Department of Hospitals for autonomous hospital corporation (s). M@ Local control through the Associated Medical Schools of Greater New York of the Federal Regional Medical Program (Heart Disease, Cancer, and Stroke); OE Central power in shaping plans of the State sanctioned ,- private Health and Hospital Planning Council, now embattled in a struggle to achieve all health planning powers in the City. And, for example, while the City and the private Planning Council have been vying for the authority and the annual millon dollars - plus appropriation as the Federal - State designated comprehensive health planning agency for the entire City, a number of foundations have granted more than a million dollars to the Community Health Depart- ment of the Albert Einstein College of Medicine to develop a plan for the Bronx alone. Y' These medical empires and their organizational fronts can be viewed as the nearest thing to regional gov- ernments of health in New York City. Yet who controls them and toward what ends? They are not subject to broad (Continued Page 2) SPECIAL REPORT " Where should we picket? " asks the poor mother, whose daughter, hit by a car, has been kept waiting for hours in the medical center emergency room after being helpless, bloody and terrified, searching half an hour for an am- bulance. " Is it the administrator's office, the mayor's office, the medical society, the drug companies, the Feds or the State? " (Continued Page 3) A De Colonization - Program for Health WHAT CAN BE done to harness these medical empires to serve the general public interest? PLANNING Authority for comprehensive health ser- vices planning must be assigned to an accountable City government agency based in citizen representative - health boards and confederated regional health boards. (See Bulletin No. 1.) Each health region and neighbor- hood should have a publicly approved - comprehensive health services plan (building from the primary level up with neighborhood health centers) to guide all pub- lic and private program expenditures and all institu- tional and professional programs. All research and teaching institutions and programs should contribute to and fit into this plan. CONTROL - The narrow Affiliation Plan approach must be ended. All municipally - owned hospitals and health centers should be directed as public institutions on a decentralized basis by neighborhood boards with em- powered public administration cadres. (See HEALTH- PAC BULLETIN No. 5 and continued inside, p. 14.) These public institutions should not be simply give- aways to all private medical empires. All community health services institutions receiving public funds, in- cluding major teaching centers, should be regulated in a comprehensive public framework and should be required by public law to have boards broadly repre- sentative of their service constituencies. FINANCE - All public financing for health and all public regulation of health insurance and facilities de- velopment must be coordinated, especially on the city- wide, regional, and neighborhood levels to assure that health services are actually financed and administered as an equal right for all citizens, based on medical need, not ability to pay. This will require, for example, public standardization through subsidy and regulation of guaranteed comprehensive equal coverage for all citizens for both hospital and basic medical coverage, (Continued Page 5) MEDICAL EMPIRES (Continued) public and community accountability. Six of the medical school centers are private, as are their major hospital centers. The seventh school is controlled State - . All these empires are essentially controlled by elite boards of trustees representing primarily narrow commercial and corporate interests (includ- ing real estate, banking, construction, insurance, drug and hospital supply interests directly profiting from these posts) and elite philanthropic groups under the managerial leadership of research and teaching oriented - and upper related - class - medical boards and administrations. There are numerous well- motivated, dedicated, and socially progressive individuals in such positions of responsibility, but the organizational basis and accountability of these empires is generally so vested and narrow that the general public interest can hardly be expected to be served. Health is prevented from being a true public issue and responsibility. Y' These empires generally have not demonstrated capac- ities for coordinating comprehensive medical services nor for reorganizing medical resources for the most efficient and ef- fective services system for their powerless constituents whose lives depend on their priorities. They have shown more inter- est in simply aggregating their own narrow institutional pro- grams and more inclination to veto the expansion of those institutions and programs in which they are not interested. They are not tightly - run, well integrated - , regionally - coordi- nated systems of service; they are loose baronies strung to- gether by teaching affiliations, research grants, fee splits, re- ferral patterns, and philanthropic kinship patterns. Often as not when they try to get themselves together formally (as with the Regional Medical Program) for actual positive coordination, it is like a John Birch Society getting a contract to develop black power curriculum. The Regional Medical Program in New York City, after one and a half years, more than a million Federal dollars, and endless elite coordinating meetings, is essentially nothing but fuzzy projections and feasibility studies. There are some particular examples of effective and appro- priate leadership - e.g., computerized pediatric bed assign- ments among Brooklyn hospitals and individual physicians creating reorganized hospital clinic programs - under medical HEALTH - PAC IS an independent, non government - center for the public, serving as a Health Ombudsman, Health Information Service, Social Analysis Laboratory, and Technical Assistance, Communications and Advocate Planning Center. HEALTH - PAC monitors public policy in the monthly HEALTH - PAC BULLETIN and in other publications, con- ducts workshops for improved community services, assists research and reporting about the problems, issues and power forces in the changing metropolitan health services setting and assists in the creation of model alternative community and regional health plans. The Burlage Report, New " York City's Municipal Hos- pitals: A Policy Review, " articulates HEALTH - PAC's policy positions and is available upon request from the HEALTH - PAC office. ' Published monthly with a supporting grant from the Samuel Rubin Foundation by the Health Policy Advisory Center of the Institute for Policy Studies, 305 Broadway, Room 1109, New York, N.Y. 10007. (212) 227-2920. Staff: Robb K. Burlage, Director; Maxine Kenny, Asst. Copyright 1968. school - major medical center auspices. But the appropriate back - up roles of such centers for the general pattern of health services have been usually performed diffidently and ex- clusively; the frequently misplaced general coordination role of such centers, sought often only for greater public financing of a private center, has been usually pursued nar- rowly and rigidly, if at all. Y' The various empire promoters - and their chosen associ- ates rule the City's health roost not as an easily identifiable coordinating group, but, as one former City health official has put it, as a private, informal " dinner party elite. " There is little coordinated, city wide - advance planning. But when it comes to shifting the pattern of City hospitals and health cen- ters control and reimbursement or rationalizing pet projects, vetoing competition, or dropping irksome or losing ventures e.g. (, St. Francis Hospital in the South Bronx, closed almost two years ago without notice to or alternative provisions for the community), they can count on a favorable report from such front organizations - as the Health and Hospitals Planning Council - that is, so long as the turf arrangements can be worked out beforehand among the barons. These empires are usually split in internal medical policy and management between two factions, both of which lack a balanced public interest view and together which lack an accountable, comprehensive public service concept for health systems leadership, as follows: THE " PATRICIANS ", primarily found among the basic clin- ical faculties and funded particularly through the National Institutes of Health and private foundations in categorical biomedical research programs, style themselves as the exalted defenders of scientific medicine. They are frequently so caught up in their own narrow projects and sub specialties - that they resent any intrusions of social reality or broad pro- fessional responsibility. These, they say, are social problems for the practitioners, for whom they see themselves as teach- ers and scientific explorers; public health administrators; and politicians - so long as they are reserved an important high priest role to " conserve quality. " THE " PROMOTERS, " on the other hand, based primarily among the deans, administrators, grantsmen, planners, and more socially oriented medical faculty, are more inclined to invoke the " social medicine " responsibilities of the major medical centers and are aware of the potential professional and institutional power these empires have for at least top- down health system reorganization. They prize the growing general HEW funds, as well as local government and private sources of service oriented - grants, for general community and administrative medicine programs and demonstration projects. They are seeking a major share of medical center finances from both public and private prepayment systems, especially Medicare Medicaid - and Blue Cross. They frequently promise programmatic results they are not really capable of delivering, based often on self serving - myths about elite and regional- centrist organizational imperatives for quality, cost and de- livery controls, in return for large public and private grants. They frequently have received such grants for which they have never developed relevant plans or staffs to implement. They are often outspoken in their demands for more " rational " and " modernized " organization of medical education, finances, planning, and services delivery - with their own vested defini- (Continued Next Page) (2) A SPECIAL REPORT (From Page 1) This special double issue of the HEALTH- PAC BULLETIN is dedicated to the proposi- tion that all citizens should know about the public and private governments that govern their lives - who, how, and why especially - the growing medical empires that increasingly con- trol the major health resources in the City in a generally unaccountable way. The Burlage Re- port on New York's Municipal hospitals de- scribes the strong general trend in the power relations of health in New York City toward affiliated empires, narrowly but powerfully based in such elite medical centers, around which government, philanthropic, professional, and commercial interests are converging. This special November - December issue of the BULLETIN and January's issue focus on case studies of two important medical empires: Co- lumbia (College of Physicians and Surgeons) - Presbyterian (Medical Center) on the Upper West Side Harlem - , and Einstein (Medical Col- lege of Yeshiva University -Montefiore) (Med- ical Center) in the Bronx. They differ in their histories, personnel, and dominant system- ideologies, although they are characterized by similar internal forces, have similar limitations, and face similar external challenges. Each illus- trates different patterns of success for the new medical system managers - who are emerging. Columbia Presbyterian - (featured in this is- sue's empire case study), more the " patri- cian, " granted America's first medical degree; its heritage is proud, exclusive, diffident, white, Anglo Saxon - , Protestant. It has just shaken off the attempt of one of the nation's most noted administrative medicine " promoters, " the en- gineer of the City's Affiliation Plan, to steer it into being a consolidated and broadly socially powerful and involved (if not so responsive or responsible) regional medical system. Einstein Montefiore - (featured as the Janu- ary issue's empire case study) more the " pro- moter, " is more socially ambitious. Built around three ceded City hospitals and projecting for the future a total Bronx " health authority " under its wing, it is only a little more than a decade old. It is the newest completely developed medical school complex in the city. It is pushed by per- haps the most accomplished medical empire- builder in America, who is based in the hospital that is the pride of the local Federation of Jew- ish Philanthropies, and, unlike Columbia, is not completely subject in expansionary em- phases to the faculty of the medical school. These sketches of the policy and power set- ting of two significant institutional complexes are designed to be a stimulus to more analysis and public discussion regarding the growth of these private medical governments that should be applied to all such growing congeries of medical power in New York and elsewhere. Each is surrounded by different constellations of interests and has different trajectories of program, but these heretofore private powers, priorities, plans, organizations, and budgets must be made more publicly visible and ac- countable as a vital step toward transforming the health system to serve all people excellently. MEDICAL EMPIRES (Continued) tions and myths about how to solve them. But they have ticularly the case in the more technologically complex major usually remained diffident, insulated, and even aggressively centers. Expanding public and private insurance and prepay- arrogant, rather than sensitive and accountable, to the needs ment programs have made more people " private patients " who of their powerless constituents. They are generally fearful can demand at least semi private - accommodations and can and resentful of the new forces of organized health consumers ask more questions about being given the same test or treat- and workers. Almost all have nothing but contempt for gov- ernment and public accountability, which they consider to be ment procedure twenty times for teaching and research pur- poses. As teaching and research programs have expanded, nothing but " second - rate administration " and " red tape. " these institutions have sought more beds and " teaching ma- ("] The empire promoters - emphasis over the last few years terial " (people) for their direct access. And, as high fixed- - on " new social responsibility " frequently has been induced cost, real gobbling - estate - centers with shrinking private phil- not only by heightened social pressure and social conscience anthropic support of their operations (less than one percent but by increasingly severe resource shortages in these estab- in many of the largest centers), they have had to obtain addi- lishments. National and State support for medical education tional sources, primarily public, of funding facilities, equip- has always lagged for behind the actual cost, as patrician ment, and land, to carry out their own physical expansions. and practitioner interests alike in the profession have tried to They are thus in fiscal reality neither private nor philan- keep narrowly defined quality high and supply low to guard thropic. " Medical urban renewal " has become a popular way reputations both their specialized and their princely pocket- books. Hospitals have always provided lucrative fee feeding- - of clearing their surrounding areas, and publicly sanctioned - , privately - planned facilities consolidation has become more stations as physicians'personal workshops in the incredibly emphasized to achieve privately accruing economics of scale inflationary medical market. They have not received an ade- for these centers. quate share of financing for their overhead and paramedical support functions, even though they have often mis managed - | The narrow growth priorities of these empires have con- tributed heavily to the inhuman fragmentation, manipulation, and mis directed - much that they have received. This is par- (Continued Page 4) (3) MEDICAL EMPIRES (From Page 3) and neglect that haunt health services, especially for the medically neediest, that have been documented in some of the following ways: Mi The rejection and dumping of " scientifically uninterest- ing " cases. Mi Dangerous and unnecessary diagnostic procedures, sur- gery, and chemo therapy - for research interests not necessarily in the best interests of the individual patient. OE Dollars to esoteric specialty programs for communities where basic medical services are lacking, such as pre natal - care, multi phasic - diagnostic screening, efficient ambulance service, and environmental health action such as against lead poisoning; and fragmentation of clinics into hundreds of spe- cialty areas, rather than convenient, comprehensive unified services. @ Draining of City service dollars to offices, equipment, staff, and laboratories for research interests at the private affiliated medical centers not contributing directly to im- proved patient care. Mi Expanding central facilities, even for primary ambula- tory services, on the grounds of the " major center, " rather than locating for the greatest convenience of the already so- cially distant population, e.g., the hoarding of bed allotments through the private Planning Council for these centralized empires alone; Columbia Presbyterian's - new ambulatory ser- vices high - rise building is to be next door rather than out in the community where it is most needed; Montefiore Medical Center is getting a top construction priority from the City, State, and Planning Council to move the old Morrisania City Hospital up to its own grounds, away from the area of greatest need. MH Professional incentives are for sub specialized - , research- based positions in the " main center, " while thousands of community physicians are excluded from participation in these centers. WM Health career lines are kept hierarchical and dominated at the top by the most prestigious medical school " scientific " graduates, are usually closed to community medicine, nursing, technician, and social service lines; admissions procedures and educational processes for advanced medical professional careers are kept narrow and rigid. As a result, thousands of nurses and aides, technicians, and ex military - medics, for example, are prevented from pursuing more excellent and responsible health careers; thousands of talented youth, es- pecially low income - and minority group persons, are discour aged from seeking such careers (e.g., current black medical school enrollments are only a small fraction of the proportion of blacks to the total population) and perhaps even hundreds of thousands of " professional sub -" health workers are trapped in paying low -, less challenging, dead - end careers for lack of institutional support and encouragement. @ Sponsorship of community health and mental health. programs and " demonstration " neighborhood health centers has been kept tightly controlled by the medical center elite, thus undermining broad citizen and health worker participation in policy and action. Hi Narrow, inter - institutional * competitive preoccupation with " latest " medical technological and biomedical engineer- ing equipment and procedures has delayed and inflated the cost of the development of new health facilities (e.g., a debate Although these empires are loosely organized and almost totally lacking as coordinated service systems, their overall resource control and responsibility is staggering. More than half of the medical institutional and professional resources (including house staffs- interns and residents) in New York City are part of such university medical center capstoned - affiliation networks. They encompass three fourths - of the volun- tary and Municipal hospital general care beds (more than two thirds - of the total); they receive the lion's share of the public and private funding for biomedical research and development, as well as academic teach- ing, and their medical chiefs are central to the national specialty panels and review committees. They control admitting and attending privileges at the largest and most important hospitals and dominate the network of specialized referral for all medical care. The poor and minority groups are almost entirely dependent on them for all their basic medical services. Their institu- tional plans are the established matrix for health facil- ities development in the city, and they have effective veto, through their grips on the State sanctioned - Health and Hospital Planning Council and on Federal granting procedures, of most institutional ventures deemed " competitive " to them. As the individual physician is the effective demand agent of drug industry advertising, major medical center chiefs are the new priests of the rapidly growing medical technology industry, which is projected to surpass drugs as an aggregate industry profit haven, with no real controls over its pricing, quality, and social distribution. about radiological equipment at Harlem City Hospital added months to already unconscionable years of delay), rather than accelerating basic modular aspects of facilities construc- tion as economically and flexibly as possible. Mi Bulldozing medical center real estate expansion has riven already disintegrating neighborhoods, displacing thous- ands and dislocating other community facilities, without any comprehensive physical and social planning and certainly with- out real community power shaping overall plans. [_] The turn to the medical empires, university - affiliated, to handle the public's medical bags has been because of the twin failures of public sector institutional management and of individual guild professional responsibility. For ex- ample, most of New York's Municipal hospitals in 1960, be- cause of red tape and long standing - fiscal and administrative neglect, didn't seem able to revamp their physical plants and programs to meet the overwhelming demand, particularly for emergency and walk - in medical services, and to recruit Amer- ican trained - house staffs and the best trained - attending staffs. There was not sufficient consumer organization and public demand (and this demand is just beginning to be heard) to restructure radically the pattern of City government manage- ment and leadership for health services. Thus, the Affiliation Plan was created quickly and loosely to get some new private professional resources and interest into these public institu- tions from some of the more prestigious private medical schools and medical centers. Some of these institutions ' leaders had been, in fact, organizing to seek turn over - to them of such public finance and institutional resources. The professional staffs recruited since then under these arrangements generally have exhibited more educational quali- fications and, with the doubling of City appropriations, have created some new and improved programs. But the widely (Continued Next Page) (4) MEDICAL EMPIRES (Continued) exposed narrowness and unevenness of time and commitment to community medical service and the diversion of expend- itures have been real obstacles to achieving balanced pro- saliance of these medical empires as the private elite guard- ians of the public's health. This was created for example, from 1960-65 by Dr. Ray E. Trussell as public health dean at grams in these hospitals. Numerous community physicians were shoved aside. The general organizational pattern in most cases is disruptive to comprehensive medical care for the community dependent on its services. Columbia and as City Hospitals Commissioner in installing and justifying the Affiliation Plan for City hospitals. [See Burlage Report for detailed description and Columbia Empire case study in this issue.] The emphases, based on a few The assumption that such institutional complexes, left to their own devices and priorities, are effective as managers studies and surveys, have been on the half truths - of " region- alization, " major medical center " quality control " and of socially responsible services or as mobilizers of compre- hensive professional resources is dubious and untested, at best. The best rated - voluntary medical centers nationally, such as Montefiore and Presbyterian in New York, select their medical markets, financially, socially, and diagnostically, " managerial flexibility, " and medical school professional " re- cruiting capacity. " All stress the primacy of the private major medical center to achieve comprehensive social goals. In contrast to the anti social - fragmentation of the solo prac- titioners and the local medical societies or in contrast to the leaving the less lucrative, lower status work and less scien- tifically interesting cases to the Lincoln and Harlem City Hos- pitals as buffers and dumping grounds, even if they are supposed to be their " social responsibility. " Their attention remains on the " major center. " present inflexibility and incapacity of most public health institutions, the appeal of such relatively benevolent autoc- racy may be strong. But the great limitations of these systems- effectiveness assertions has already become obvious, as follows: This is also related to the trend of convulsed local govern- Wi " Regionalization " around a " major medical center " as ments relying on " multiversities " as the new ad hoc practiced thus far (it has never been systematically applied- governments of embattled megalopolis. Not only has New York City expropriated its Municipal hospitals in this direc- tion; it has based its air pollution control Department - of Air Resources at Cooper Union Engineering College; it has had numerous proposals to turn disputed public school dis- only as a rationalization for certain institutions'expansions as opposed to others) has given top heavy - emphasis to the pri- orities of the major medical centers and little power and focus to the decentralized needs of community health services convenient for all citizens. tricts over to private institutions to operate; it has had its displaced Ocean Hill Brownsville - teachers offered to Harvard and refresher - coursed at City University. The City has now contracted with private management consulting firms to study how to give almost all City functions over to universities, quasi public - corporations, and other enterprises on a cost- plus plus - contract basis. So goes Fund City into the new era of the Fast Deal. A new medical myth pattern has emerged to defend the I The asserted " quality control " of such major teaching hospitals has been shown only for particular specialized treatment and diagnostic procedures; it has not been shown to be an effective social milieu for comprehensive diagnosis and medical continuity. HI As noted above, the so called - " managerial flexibility " of such institutions has been due more to greater budget margins and market selection power than to inherent social (Continued Page 6) A De Colonization - Program for Health (From Page 1) not separate packages and agents; elimination of ex- cessive and fragmentary fee provisions for reim- bursement; public, vigorously enforced admissions review procedures for all hospitals and centers based only on need and availability; and interdisciplinary and broadly - based professional review of medical quality for all services. More direct expenditures for vital sup- port services are needed at the most burdened Municipal hospitals. Greater State and Federal financ- ing and better structured private financing is needed for basic medical education programs and institutional support and for carefully planned, advanced and super- specialized medical procedures and technologies to re- lieve the present drain and diversion from primary health service programs and basic support services. Until a publicly planned, rational structure of health services delivery is created, merely expanding the cur- rently irrational private financing market will prove to be inflationary inflationary and ineffective. MANPOWER Responsibility - for flexible, comprehen- sive, and continuing education opportunity and open career ladders in health must be achieved by better integrating, modernizing, and humanizing all health sciences curricula, training, and certification processes. All medical schools receiving public financing (that is, all of them) must be required to link their programs with the full range of health career development and to be accountable to the pressing social need for full health career opportunity in the surrounding community, as well as nationally. (An example of such social need coming alive in new, direct social pressure is the en- tirely reasonable demand being made by medical stu- dents and the surrounding ghetto communities for all Philadelphia medical schools to change their anti- quated and institutionally racist admissions and educa- tional processes to admit at least one third - black stu- dents in next year's entering class; this spirit is spreading to New York City and elsewhere.) (5) MEDICAL EMPIRES (From Page 5) administration capacity. WM Medical schools " recruiting capacity " has usually been more for narrow, research - oriented physicians than for de- veloping broadly community - service - committed physicians ca- pable of functioning effectively in the field. [| As political buffers, the empires have not worked out. In the Affiliation Plan, some City leaders evidently hoped to use. these private empires as social administrators and buf- fers to get away from the political pressures of City govern- ment. However, the attempt of these institutional complexes to wield autocratic power is meeting with growing resistance from emerging consumer and health workers forces becoming aware of the public utility nature of such institutions, as gov- ernment and community finance become the prime basis of their support. (See, e.g., Columbia Empire case study, pp. 7-13.) Throughout the City, neighborhood health councils have sprung up demanding control over neighborhood health cen- ters and community hospitals and seeking empowered neigh- borhood boards for health. Hospital worker unions are de- manding new prerogatives and accelerated training and ad- vancement programs in all the major hospital centers, both Municipal and voluntary. Political leaders, such as Bronx Borough President Herman Badillo, have been critical of elite plans to make these empires (e.g., Einstein Montefiore - in the Bronx) into autonomous authorities. Even health science stu- dent groups are challenging the autocratic power of the medical empires at schools such as Columbia, Einstein, and NYU and are seeking alliances for broader community control of health services. The keys to countervailing the limitations and incapacities of these private medical empires are (1) to direct emerging consumer, worker, and community - oriented health professional forces into effective demands against the real structures of health power, and (2) to restructure local government and community health leadership capacity so that the missing link of publicly accountable planning, regulating, and co- ordination of all health services is achieved. (Some crucial policy and action requirements for harnessing and redirecting these medical empires are enumerated in the box at the bottom of Page 1: " A De colonization - Program. ") Each of the seven medical schools in the city has staked out imperial networks with varying degrees of interest and . coordination. In addition to EINSTEIN MONTEFIORE - in the Bronx and COLUMBIA PRESBYTERIAN - on the Upper West Side (See case studies in these issues) -NYU BELLEVUE - is rather diffidently based on the Lower East Side - the new MT. SINAI school and complex (its first entering Medical School class is this year) is based on the Upper East Side but has ties in Queens (which has no medical school and is up in the air with regard to medical ties) and through affiliated Beth Israel Medical Center (which is be- coming a power in its own right and may seek medical school empire status of its own) on the Lower East Side- South DOWNSTATE - Medical Center (SUNY) is attached to mammoth Kings County City Hospital in Brooklyn but has stepped back into its own private university hospital with loose affiliation ties to most major voluntary hospitals in Brooklyn CORNELL ,L based on the Mid East - Side, with ties in Queens and Westchester, serenely refused even to get involved in development of City hospitals in recent years and appears to have more commitment to scientific pur- suits at its own present centers and to private and subur- ban medical practice - NEW YORK MEDICAL COLLEGE (Flower Fifth Avenue), now based with Metropolitan City Hospital in East Harlem, is eyeing a new location in Westchester County, leaving the Upper East Side situation in doubt - the Catholic Charities have a scattered set of institutional establishments of their own, the largest being the Catholic Medical Center plan for Brooklyn - Queens (a confederation of a number of hospitals), the most prestigious being St. Vincent's, (affiliated with NYU, in Greenwich Village, Lower West Side), and also including Misericordia (now affiliated with Fordham City Hospital, growing under the fraternal eye of Einstein Montifiore - , in the west central - and upper Bronx Polyclinic) -French - Med- ical Center (now in Chelsea, Manhattan) is cooking up dramatic plans for a major new complex somewhere in the City, but apparently has yet found no turf completely safe for its autocracy. City Health Services Administration planners admit that these geographical empires are accepted as basic defining units for much of their own plans for affiliation in ceding of Municipal hospitals and health centers and that they are central fo plans for creating about 10 large health districts or regions in the City sometime in the future. [See Empire Map in centerfold.] Who Plans? Rocky Lindsay - Hold Key THE ISSUE of who will form the new Federally - funded and State endorsed - comprehensive health planning agency for New York City may result, as usual, in a tug war - of - within the majority of broadly representative consumers on the commis- sion and for major emphasis on the creation of neighborhood health planning boards. Republican two party - system Governor - Rockefeller and Mayor The State Health Planning Commission has created a rigor- Lindsay. ous obstacle course of requirements and a deadline of January Down to the wire twice now has gone the local round of 5 for local applications to be eligible for Federal funding by competition between (1) a sometimes reluctant City proposal next July 1, but the local application process may drag on for a Mayor appointed - , more consumer - oriented public agency much longer. The State earlier this fall turned down both the and (2) an aggressive Health and Hospital Planning Council preliminary City and HHPC proposals as being too unrepre- proposal for a self appointed - , provider dominated - elite - , " quasi- sentative of consumers, too vague and incomplete, and prima public " continuation of its own power (see BULLETIN No. 1). facie lacking consensus. Some close observers predict that if Meanwhile, the City wide - Health and Mental Health Council, neither the City and citizens groups nor the HHPC proposals (representing most neighborhood health councils and health- show enough strength or " consensus, " the Governor might interested neighborhood organizations, plus some other groups) attempt to replace the now State sanctioned - HHPC with a has threatened submit to a separate " peoples'proposal " to new " regional commission " directly under the State Commis- the State, unless a strong position is taken by the City for a sion, to be chosen primarily by the Governor himself. (6) Empire Survey (I) COLUMBIA P & S: Medical Gymnasiums? THERE ARE RUMBLES in the Columbia (College of Physicians And yet, & P S is, in some ways, a reluctant empire, par- and Surgeons) Medical Empire that some observers think may ticularly with regard to establishing itself as a vast service be heard around the world. On the " downtown " Columbia organization in the Harlem Washington - Heights area. Faculty campus (around 116th Street - the medical campus is " up- patricians have been highly resistant to medical empire pro- town " around Columbia Presbyterian - Medical Center, west of moters on its own faculty and staff. December 1 at P & S one 168th Street and Broadway), world infamous - for its gymnasium of the nation's most prominent aggregators and defenders of and defense contracts - inspired campus siege of last spring, academically - based, private medical empires (Dr. Ray E. general faculty and students now talk about the vulnerability Trussell) threw in the towel and headed for a major hospital of Columbia " medical gymnasiums " uptown. They fear that administration post on the Lower East Side. these might at any moment get Columbia into even more mo- Who rules the empire? mentous warfare with the Harlem and Washington Heights P & S, loosely chaired by Dean H. Houston Merritt, operates communities. What is this medical Columbia all about? It is a medical as a confederation of departmental baronies held together by research and publishing contracts and an endless input of teaching, research, and special institutional service complex graduate student and house staff apprentices whose careers concentrated in the Washington Heights - Harlem - Upper West depend on their blessing. Dean Merritt surrounds himself Side area of Manhattan that is built around Columbia - Presby- with " associates " as expediters and deflectors, such as old- terian Medical Center, the largest voluntary hospital center liner Dr. George A. Perera (dean of students and of admis- in New York City; two other major voluntary teaching hospitals, sions, who recently urged a crack - down on student beards St. Luke's and Roosevelt, and two Municipal hospitals with and long - hair); liberal more - - liner Dr. Douglas S. Damrosch (al- which it is affiliated Harlem Hospital Center and Francis though he was the administrator responsible recently for deny- Delafield. (See empire map in the centerfold of this issue.) ing P & S meeting space to employees wishing to discuss the The entire P & S complex includes more than 4,500 hospital 1199 unionization campaign); and research prestigious - Dr. beds, including more than 1,540 at Presbyterian and 885 at Melvin D. Yahr (a noted neurologist, as is Dr. Merritt, director Harlem City Hospital Center, and involves the annual train- of the well known - Parkinson's Disease Clinic, and the Dean's ing in the hospitals of about 750 interns and residents. emissary to Harlem, known for his effective use of Negro The World Is Its'Region ' physician - liaison figures there). Columbia Presbyterian - and the other hospitals in the empire - The Columbia P Presbyterian & S - Medical Center complex operate essentially as businesses living between the courtier is, in fact, an international professional organization with a tastes of the prestige medical faculty and the philanthropic, sprawling institutional base, living out the expectations of and finance, real estate, and special program interests of the depending on the support of the U.S. corporate and govern- trustees. Presbyterian Executive Vice President - Alvin J. Binkert ment world. It is difficult, to say the least, to " regionalize " is the expediting chief - he even operates, sans M.D., as a locally and to assert popular community control over an powerful member of the Medical Board. Significantly, Merritt essentially closed corporation (see e.g., James Ridgeway, and Binkert are co chairmen - of the Joint Committee of the The Closed Corporation, Random House, 1968, on uni- Faculty and the Medical Board of the Facilities of the Medical versities as businesses) that, for example: Center and are known empire - wide as the " Joint Committee. " -Had in 1967 over half of the Federal government The Trustees of Columbia University, of course, are already contracts (about 400) and more than third one - of the annual celebrated from last spring's dispute as a kind of uptown rate (about $ 22 million) of such Federal funding of the approximation of the executive committee of the U.S. ruling total Columbia University budget primarily - from the Public class with some Columbia urban renewal and real estate Health Service and the National Institutes of Health; hanky panky - thrown in. (See, e.g., the North American Con- -Has microbiology research contracts with the Army and gress on Latin America pamphlet: Who Rules Columbia?) the Navy; , Columbia Presbyterian's - trustees are an overflow, interlock, -Has research and training outlets in Beirut, Taipei, Buenos and continuity with the University trustees in personnel and Aires, and on private rubber plantations in Latin America; in social disposition - primarily corporate - financial and Re- -Beyond its own immediately affiliated institutions uptown publican (including Lucius D. Clay, Robert B. Anderson, and has major Brooklyn and Cooperstown hospital center affilia- Robert D. Murphy). Trustees of Roosevelt and St. Luke's affi- tions and has attached to its faculty the directors of pathology liated hospitals consist more of New York philanthropic and at 52 hospitals in the greater New York area; civic types who probably must take their lead from the " big -Has as the president of its major teaching hospital a boards " both financially and medically. Texaco director and has the president of U.S. Steel chairing the finance committee and the president of AT & T chairing the Is Harlem Burning? planning and real estate committee; What is the rising discontent in the surrounding community -Has the presidents of a number of national professional around the immediate Columbia Medical Empire environs specialty associations and the chairmen of numerous National that is threatening its present state of enterprise? Institutes of Health project committees on its faculty; WA A disparate (and, in some cases, desperate) set of black -Has a former medical school dean as a department chair- physician and community forces, prominently centered in Har- man, supplied from its professorial ranks the new dean of lem CORE's " Committee of 100, " have been calling (and New York Medical College a year ago, and just spun - off form- erly affiliated Mount Sinai Hospital as a new medical school. threatening) for a powerful Harlem Community Health Board. (Continued Page 8) (7) EMPIRES MEDICAL EMPIRERESS 4 (New York Medical College & plans to move to Westchester) 8 Y,sa 28 Y- 12 Staten Island J # TM30 29 31 Bronx 34a 44 48 20 35 13 Queens -15 36 14 39 Y' 8a < 53 (50 H Brooklyn 4) Medical Center 1 ~~ #P Voluntary Hospital @ City Hospital S Other Public Hospital Y' Neighborhood Health Center Manhattan +4 Community Mental Health Center A. Columbia University - College of Physicians & Surgeons Empire 1.2 .1 .N ePrwe sYboyrtke rSitaant Heo sPpsiytcahli atric Institute 3. 3. Francis Delafield Hospital 4. 4. Harlem Hospital Center 5. 5. St. Luke's Hospital 5a. Riverside Neighborhood Health Center [In addition to listed functioning neigh- borhood health centers, more than 40 are projected by 1973 in the City budget, most of which will be part of the major medical center empires.] , 6. 6. Roosevelt Hospital 7.8 .7 .B rMoaonkhdaatlea nH oEsypei,t aEla rC e&n tTehrr o(aBtr oHookslpyint)a l 8a. Brownsville Neighborhood Health Center B. New York Medical College Empire 9. Flower Fifth Avenue Hospital 10. Metropolitan Hospital 11. Bird S. Coler Hospital & Home 12. St. Vincent's Hospital (Staten Island) 13. Flushing Hospital (Queens) 14. Interfaith Hospital (Queens). 15. Jamaica Hospita! (Queens) 16. Wyckoff Heights Hospital - Main Division (Brooklyn) 17. Lutheran Medical Center (Brooklyn) C. Mount Sinai Medical College Empire 18. Beth Israel Hospital 19. Gouverneur Ambulatory Care Unit 20. Elmhurst Hospital (Queens) D. Cornell Medical College Empire 21. Hospital for Special Surgery 22. Memorial Hospital 23. New York Hospital 24. James Ewing Hospital E. New York University College of Medicine Empire 25. Bellevue Hospital 26. Veterans Administration Hospital 27. St. Vincent's Hospital 28. Goldwater Hospital F. Yeshiva University - Albert Einstein College of Medicine Empire 29. Montefiore Hospital 29a. Neighborhood Medical Care Demonstration. [Health Center] 30. Veterans Administration Hospital 31. Morrisania Hospital 32. Lincoln Hospital 33. Bronx Municipal Hospital Center 34. Bronx State Hospital & Kennedy Mental Retardation Center 34a. Throgs Neck Community Mental Health Center [This is the only operating community mental health center of approximately 18 centers projected as part of these major medical center empires.] G. Catholic Medical Center Empire [The Catholic Medical Center is a concept, not an actual institution, which will eventually in- clude a medical school. Capital construction on the six Catholic hospitals listed below will ex- ceed $ 60 million.] 35. St. John's Hospital - Queens 36. Mary Immaculate Hospital 36a. Neighborhood Health Center. 37. Queens Hospital Center (partial affiliation with Mary Immaculate) 38. St. Joseph's Hospital 39. St. Mary's Hospital 39a. Neighborhood Health Center 40. Holy Family Hospital 41. Providence Hospital (under construction) H. State University of New York Downstate - Medical College Empire 42. Long Island Jewish Hospital (Queens) 43. Greenpoint Hospital (affiliation with Brooklyn Jewish) 44. Long Island College Hospital - Main Division 44a. Long Island College Hospital Prospect - Heights 44b. Red Hook Neighborhood Health Center 45. Cumberland Hospital (through affiliation with Brooklyn Hospital) 46. Brooklyn Hospital 47. Methodist Hospital 48. Veterans Administration Hospital 49. Coney Island Hospital (through affiliation with Maimonides Hospital) 50. Maimonides Hospital 51. Jewish Hospital of Brooklyn 52. Brooklyn State Hospital 53. Jewish Chronic Disease Hospital 54. Kings County Hospital Center COLUMBIA P & S age citizen in the Columbia Presbyterian - empire underlies such demands for community control. A large proportion of (From Page 7) institutional operations at these Municipal and voluntary They want community control not only of Harlem City Hospital teaching hospitals is subsidized by City, State, and Federal but of all health services in the greater Harlem area, similar tax dollars (direct City appropriations, affiliations, City charge - to Ocean Hill Brownsville - school board control. Black physi- reimbursement, Medicare, Medicaid, Federal service program " cians are angry about being esse ntially excluded from impor- | grants, etc.). Only about one half - of one percent of the tant positions in the academically - controlled Columbia - Presby- Columbia Presbyterian - Medical Center operating expenses terian network and for the difficulties they face in getting were covered by private philanthropy in 1967. And yet, elite their patients admitted to the best services. Harlem people university and hospital " philanthropic " trustees have the basic have been deeply frustrated about the slowness of the new decision - making power, and programs are designed primarily Harlem Hospital building, finally scheduled to be opened in to meet faculty research and teaching interests, not to assure early 1969 after literally decades of anticipation and a capital budget promise since the late 1950's. " A rock in the ground would grow faster, " chimed one Harlem militant. A citizen's suit against Mayor Lindsay and the Department of Hospitals is now pending in the New York County division of the State Supreme Court to order immediate correction of numerous violations at Harlem Hospital of the State Hospital Code and of the City Health Code acknowledged in State testimony by City Hospitals Commissioner Terenzio. Up Tight - at HHC OE New issues are arising (even from within the Harlem- Hospital - based medical staff itself) about the actual design and utilization of the new building and of the old. The new hospital will have outdated, charity - era, six person - wards, officially ineligible for Medicare - Medicaid semi private - care reimbursement and illegal under the 1966 State Hospital Code. Adequate provisions for basic pediatric, pre natal -, and ob- stetrical care services will not be available. Use of the old buildings is scheduled to emphasize psychiatric services, pri- marily for psychotic care and research space. (The Harlem Hospital Department of Psychiatry is headed by Dr. Elizabeth Davis, recently wed to Dr. Trussell.) Severely neglected, for example, is the need for vastly expanded narcotics treatment, rehabilitation, and social action programs. Central Harlem has no real narcotics detoxification program, even though it has one of the highest addiction rates in the nation. Ml Promoters of the independent Board proposal, such as CORE's Victor Solomon, wish to channel the millions of pub- lic dollars now going through Columbia (e.g., more than $ 11 million annually for its Harlem Hospital affiliation contract. alone, including more than a million dollars for " profit ") comprehensive services for the surrounding community who depend heavily on these institutions for most of their medical services. Harlem Hospital, although supported by a generally quite dedicated medical and paramedical staff, is forced to be a surgery - happy buffer and " receiving " hospital over- whelmed by the patients dumped on them by surrounding Columbia - affiliated voluntary hospitals, especially Presbyterian. Some of a new breed of socially committed - young physicians are now being recruited among the Harlem house staff, but it still shows the strains of being the assignment where blacks are exiled and where those " with a yen to cut " are attracted. It is reputed to be one of the best hospitals in the world to be treated for acute trauma, such as gunshot and stab wounds. But the specialty clinics have waiting lists from three weeks to two months. The pressure of patients hurriedly dumped because of scientific disinterest or economic socio - aversion was expressed dramatically with one elderly patient who was hustled out of Presbyterian so quickly the tubing was still hanging loose from an incompleted intra veinous - procedure. W@ Delafield City Hospital, an inefficiently utilized, under- staffed, and under supported - Municipal hospital created pri- marily for the treatment of cancer and chronic diseases, has been threatened with closing unless P & S decides to use it as a general research hospital. It has no real ambulatory or emergency services for the surrounding Washington Heights community - one resident commented that " no patient enters the hospital's gates on his own unless he's lost. " Even Harlem Hospital dumps patients on Delafield! Sell - Out or Close! directly into the community's hands for basic policy making - . OE Sydenham City Hospital, located southwest of Harlem They are seeking this either through community - controlled Hospital, and the only unaffiliated Municipal hospital left in decentralization of the City Health Services Administration or even through direct State government intervention to delegate the city, has also been threatened with closing, evidently because P & S isn't interested in it. Thus far, such closing has such control to the community, as CORE has proposed for Harlem schools. Even representatives of the two major hos- been successfully resisted by the surrounding community. It was recently reported that Columbia was considering the de- pital employees unions at Harlem, Local 1199 of the Drug velopment of a private " black physicians pavilion " adjacent and Hospital Employees Union for private affiliated - employees to Harlem Hospital as a substitute for Sydenham and as a and District Council 37 of the American Federation of State, plum for the more dutiful and negotiable black physicians County, and Municipal Employees for most directly employed and old line - Harlem political leaders. But no formal word (unaffiliated) City hospital employees, favor decentralization has been forthcoming, and the internecine faculty troubles away from the existing Columbia and City Hospitals bureauc- about Harlem Hospital alone may have at least temporarily racies. (1199 has thus far been unable to get union recog- vaccinated P & S against additional Harlem expansions. nition at the key Columbia - affiliated voluntary hospitals of Mi Knickerbocker Hospital, unaffiliated voluntary, calls Presbyterian, St. Luke's, and Roosevelt, but is currently itself " the City's only voluntary municipal hospital " because spiritedly organizing research, clerical and laboratory workers of its density of low income - Harlem patients. It has created at P & S. Such employees are being harrassed by P & S " manage- an imaginative new hospital plan, including a community cen- ment " by being denied meeting rooms, etc.) ter and low cost - housing, but it also faces acute financial and OE Deep seated - community anger regarding the, at best, medical staffing difficulties without more P & S association and hand down - me - nature of most services available for the aver- interest. (8) A determined community resistance to Columbia & P S elite plans for a 20 milli-o ndo l-l ar Washington Heights - Inwood Community Mental Health Center high - rise building (with, for example, literally segregated entrances between the pre- dominantly black Puerto - Rican and white communities) has the psychiatric promoters at Columbia and on the City's vested Community Mental Health Board (which has ceded the center to Columbia) very much on edge. (See the statement by Dr. Lawrence Kolb, P & S Psychiatry Chairman, in related quotations box. It should also be noted that Columbia's Dr. Herbert Fill is Acting Commissioner of the Board and that - Columbia's Dr. Gursten Goldin is one of the four physician members of the city wide - Board.) With the support of in- dependent service agencies in the Washington Heights community, chiefly Dr. Rubin Mora's Puerto Rican Guidance Center, an ad hoc community organization is developing its own plan for control and operation of the center and program. This committee is demanding a program emphasizing on the- - street services aimed at immediate social and personal prob- lems, rather than only the hospital treatment of psychoses in " Columbia's psychiatric skyscrapers. " The ad hoc com- mittee's " vote - in " take over - of a Columbia professional advisory meeting in September was supported by every- one from city wide - socially activist psychologists and Columbia medical students associated with the Student Health Organiza- tion to Harlem black militants and Columbia Students for a Democratic Society. No Place for Everyone Wi The astonishing fact is that, with one of the greatest densities of low income - ghetto population in the world, with some of the most shocking indices of medical deprivation (infant mortality, maternal mortality, undiagnosed chronic disease) and with relatively poor actual physician coverage- despite all these different hospital facilities around the Columbia empire - the greater Harlem Washington - Heights area does not have a single truly excellent, comprehensive " community hospital'or neighborhood " family medical care " center (ambulatory care) which is available to all citizens. New neighborhood health centers are in operation or are being developed on the Mid West - Side around P S's & other major voluntary teaching hospitals in the empire, St. Luke's and Roosevelt, and are eventually planned for Central Har- lem. But, thus far, truly excellent, comprehensive, convenient, and openly available facilities and services are lacking. It is no wonder, then, that Harlem residents refer bitterly to the recent publicity for example, about Dean Houston Merritt of P & S rushing to treat Portuguese dictator Salazar for a severe stroke (when most Harlem stroke victims are considered scientifically uninteresting at Presbyterian); about the rise of a new 15 story - private ambulatory care facility next door to Presbyterian for the private and semi private - pa- tients of P & S Faculty (when such ambulatory services are most desperately needed for all citizens closer and more con- venient to the areas of greatest need); and about (the ulti- mately ill fated -) Columbia speculative sponsorship of a new cigarette filter or its recent receipt of grants for development of advanced organ transplant engineering (when a few more dollars and more attention for pre natal - care might save the lives of thousands of infants in Harlem over a period of time). In that sense, Columbia's reputation as a major center for the treatment of, for example, heart disease and stroke, makes it all the more anathema to the surrounding community. (Continued Page 10) (9) The Charge.. " The universities and the medical profession are the trustees of the essential knowledge which will contribute substantially to the solution of the problems of individual and national well being -, happiness, and vigor... The role of the medical center is in direct response to the obliga- tions of medicine and hospitals to meet conditions in this changing world... It reaches its fullest measure of usefulness when adequately supported by the medical and allied professions, the community it serves, state and private financial resources for training, research and patient care and, above all, by the continued educational lead- ership of the university. " -Dr. Willard C. Rappleye, Dean, College of Physicians & Surgeons, and Vice President - , Medical Af- fairs, Columbia University, 1931- 1958; former Hospitals Commis- sioner, City of New York; present member, NYC Board of Hospitals. " Columbia [] ... has established a local community surrounding the Columbia Presbyterian - Medical Center as a laboratory for long term -, intensive studies of mental health procedures, therapy and epidemiology of mental health......... It would seem far preferable to apply current psychiatric insight through appropriate change inducing - techniques, including community action... " -Drs. Lawrence Kolb, Ray E. Trussell, et. al., College of Physicians and Surgeons, American Journal of Phy- chiatry, May, 1961. " We are trying to bring the resources of our great vol- untary institutions together with the stability of the tax resource the most stable source of money that you can relate yourself to as an operating agency... even the survival of some of our finest hospitals depends on the ability of our voluntary hospitals to do their teaching and research in City operated municipal hospitals. " -Dr. Ray E. Trussell, Commissioner of Hospitals, City of New York, 1961-65; Associate Dean (for Public Health), Columbia College of Phy- sicians and Surgeons, 1955-1968. (Statement in 1963) " In New York City there are few issues in medical care which do not exist and about which we are not trying to do something. Because of the ethnic and economic com- plexities in New York and its importance as an international cross roads -, if we here cannot solve the intense problems which exist, the world will view us with skepticism. " -Dr. Ray E. Trussell, 1964. " The former Commissioner of Hospitals in New York City also made an effective approach to improving the quality of care by affiliating each municipal hospital with a great teaching hospital or medical center. These are the innova- tions that the leaders in every large city will need to follow in the future. " -Dr. Ray E. Trussell and Dr. Herman Hilleboe, Columbia School of Public Health and Administrative Medicine, 1966. Columbia P & S (From Page 9) This is because it can't assure the delivery to many people of even the most primitive medical assistance against these killer diseases and because it functions more as a diffident veto power than a program innovation center, e.g., given the experience thus far with the Federal Regional Medical Pro- gram (heart disease, cancer; and stroke) in New York City. Hf There is also community bitterness about the seem- ingly insurmountable educational walls around P & S to blacks and Puerto Ricans. Only about ten black and Puerto Rican students are now in the entire P & S medical student body (of about 450) and, except for the nursing school, there are precious few Columbia para medical - and new health careers development programs. (City University and Mount Sinai Medical College plan to establish a four year - health careers college in East Harlem within the next year or so.) Little effort has been made to recruit socially disadvantaged students or to enrich the P & S curriculum and educational pattern to be- come more relevant and accessible to them. Rather than re- considering the discriminatory socio economic - narrowness of its student selection - stressed in demands for change being made by current medical student leaders themselves - the P & S catalog boasts only of the super scientific - excellence of its past selections. Enemies Within What are the internal political struggles that have sent the Empire's most strident promoter elsewhere? Dr. Ray E. Trussell, as City Hospitals Commissioner, 1961-65, engineered the Affiliation Plan for City hospitals, while hold- ing (on leave) his chair as Associate Dean (for public health) at Columbia College of Physicians and Surgeons. Almost single handedly - he got & P S into the Harlem hospital and mental health business (most prominently through affiliation with Harlem City Hospital Center) and away from its tradi- tional downtown attachment to massive Bellevue City Hospital. Columbia School of Public Health and Administrative Med- icine, part of P & S, had been the base for studies Dr. Trussell directed which ultimately reinforced the position of the major voluntary hospital establishment in New York City for hos- pital planning, medical quality control, and hegemony over all Municipal hospitals and health institutions. (See the Burlage Report for detailing of the intellectual and political history of the Affiliation Plan developments.) More than half of the present administrators of New York Municipal hospitals, including the three hospitals which are part of or surrounded by the Columbia Empire Harlem - , Delafield, and Sydenham- were trained in the hospital administration program of the School, most of whom were trained and recruited under Dr. Trussell as Associate Dean Commissioner / . For 13 years Dr. Trussell had attempted to coax, cajole, consolidate, and then to captain Columbia P Presbyterian & S - out of its traditional, patrician self possession - (the medical faculty was founded in pre Revolutionary - 1767 and awarded the first M.D. granted in the Colonies) into the more downtown - Columbia vogue of geo- graphic expansionism. Before him, Dr. Willard Rappleye, long time - P & S dean, once an on leave - City Hospitals Commissioner himself and today a member of the City Board of Hospitals, had emphasized more cautiously that it is in the self interest - of private medical centers to accept more public institutional responsibility in return for public dollars to substitute for the proportionately sinking private support of medical education and of voluntary hospitals. But this lesson has been learned hard - in the very place where it seems most applicable - New York City's tradi- tionally publicly supported - private university, which has faced in recent years more competition from a growing City Uni- versity, a massive new State University system, and, in the medical field, from a number of upstart medical schools (now seven others in the greater New York area) and medical centers. Dr. Trussell has left Columbia to become Medical Director of an openly more expansionary medical complex, Beth Israel Medical Center on the Lower East Side. He may have con- cluded that the resistance to certain kinds of medical center promotionalism can be even tougher at home base among the faculty patricians, particularly without an independent institu- tional base of your own, than it is out in the field among the practitioners, the proprietaries, the politicians, and, of course, the people. (Dr. Trussell's medical quality studies at Colum- bia have been aimed primarily at un certified - practitioners, particularly those performing surgery, and at proprietary hos- making pitals - profit - , usually owned by physicians - spawning questionable surgery and medical practice as well as beds competitive with and costly to the major voluntary hospital- voluntary hospital insurance establishment.) Many of these P & S faculty patricians undoubtedly blame Dr. Trussell and his associates for getting them into the " turbulent " environment of Harlem and Washington Heights in the first place. The narrowest of this exclusive spirit was expressed in a recent Science magazine interview with one Columbia researcher, who commented: " It's a nice life [here], especially for the senior faculty and the scientists. We have plenty of money for our graduate students and we don't have to teach too much. " Columbia Presbyterian - Medical Center was recently ranked by a national magazine as one of the top hospitals in scientific development but as one of the worst in community responsibility. (The potential convergence of interests between health science students who aren't being taught in a relevant setting and the surrounding community residents who don't have available the relevant medical services becomes more obvious.) There are some medical faculty and a number of medical students who identify with the spirit more of the surrounding community that it's not WHETHER Columbia should aim more of its medical resources and institutional armentarium toward community needs but HOW, FOR WHOM, and CONTROLLED BY WHOM? But, in any case, there certainly is trouble " out in the field. " Self Inflicted - Wounds The internal power struggles during the last decade between particular faculty patricians and promoters over, for example, the shift from Bellevue to Harlem, has distracted energies of the P Presbyterian & S - empire at the very point when it re- quired a more even, comprehensive leadership. It has needed urgently to modernize its academic and scientific programs, while expanding to meet new social responsibilities in an appropriate manner. Internal resistance to integrating P S's & precious resources with the surrounding community has in some cases had direct academic backlash effects. One of the prime reasons given for the School of Dental and Oral Surgery losing its national accreditation was lack of access to a meaningful scale of patient population. When the School of Public Health (10) lost its accreditation earlier in the 1960's, it was commented that much of the faculty was doing consulting or was active somewhere else in the nation or world (the School is even providing back - up for a Latin American Center for Medical Administration - medical counter insurgency - and all that - in Buenos Aires, Argentina) and was not spending the time doing effective teaching and service preceptorship in the immediate environs. The struggle over Bellevue - Harlem goes back at least to the late 1950's. A number of prominent faculty figures, such as Dr. Dickinson Richards, Nobel Laureate in cardiology of the P & S Department of Medicine, had triggered a drive in the late 1950's through the Committee of Interns and Residents and the Better Bellevue Association to re staff -, re build -, and re equip - City hospitals, beginning with Bellevue (& P S then had a wing of Bellevue along with NYU and Cornell). Ironically (for P & S opponents of Dr. Trussell), this was an important spark in setting off the drive to do something dramatic about City hospitals that culminated in Dr. Trussell's Affilia- tion Plan, thanks especially to the push of the major volun- tary hospital establishment. There had been a lot of dissatis- faction at P & S about the general City support of Bellevue and the distance of the hospital on the Lower - Mid - East Side from P & S. But, on the other hand, some of the faculty Belle- vue exposers - were loathe to move into darkest Harlem, which was thought by many to be the worst physical plant combined with the most overwhelming patient population in the city. Besides, if you start seeing people at Harlem, who knows, they might start thinking they can see you at Presbyterian --- and then what will it all come to? A wing at Bellevue seemed manageable; an open door to Harlem seemed, as Dean Merritt observed (see statement in box of quotations), a more " un- limited " commitment of P & S resources. Harlem End Run - Dr. Trussell, first as public investigator (study director of the Mayor's Commission on City Hospitals in 1959-60) and then as Hospitals Commissioner, was eyeing Harlem Hospital as the logical step of Columbia involvement and as a pos- sible end - run around the patrician faculty forces at P & S. He helped push, from the City side, to get Columbia out of Bellevue and, lacking the support of the Department of Medicine at P & S, almost literally signed a contract with himself between the City (as Commissioner) and P & S (as Director of the implementing School of Public Health) -in 1961, one of the first major new affiliation contracts. The Public Health School, at least in the short - run, had to mo bilize much of the medical staff for Harlem, because of Medicine's initial veto. For more than six years the faculty cold war went on, but the Columbia - Harlem Hospital relation- ship thickened, while it became obvious that Columbia's days at Bellevue were numbered. In 1967-68 (the last Columbia medical divisions were transferred last July), NYU took full control at Bellevue and P & S moved its Bellevue Division time full - staff and house staff rotation to Harlem, Presbyterian, etc. In a related move, P & S left Goldwater City Hospital (for chronic care on Welfare Island) to an NYU City affiliation and shifted its medical staff there to Delafield. The Departments of Medicine and Surgery, as much to pre empt - Dr. Trussell, the Public Health School, the Depart- ment of Psychiatry and others as to accept real program- matic responsibility, and other & P S departments now have most control over the Harlem affiliation. (This loss of a foot (Continued Page 12) The Resistance.. * " Although the medical - center concept may be ideal it is not always possible or even desirable to concentrate all the clinical facilities of a community in close association with the medical school... A problem arises... when a medical school is called upon to help a voluntary or municipal hospital improve its care of patients and train- ing of the intern and resident staff. The capabilities of the faculty are not unlimited. Dissipation of their energies may impair the efficiency of their teaching and their research potential. Each school must examine its conscience to de- termine how far it can go in helping to solve this problem. " -Dr. H. Houston Merritt, Dean, College of Physicians and Sur- geons, at a symposium, June 4, 1964 (after P & S had been af- filiated with Harlem Hospital Center by Dr. Trussell as Com- missioner of Hospitals). " Columbia is discriminating against black doctors and is mistreating black patients at Harlem Hospital. " -Hon. Adam. Clayton Powell, U.S. Congressman from Har- lem, Summer, 1968. " A Harlem Community Health Board must be established to control all of the medical and mental health services and whatever such facilities exist in Harlem... any affiliation of any hospital would take place on the basis of contractual relation with the community... " " -Statement of the " Committee of 100, " Summer, 1968, including representatives of Harlem CORE, HARYOU - ACT, Harlem Neigh- borhood Association, Harlem Hos- pital employee unions, and Har- lem community physicians and hospital staff. " Those who work in the heart of Harlem Hospital know best how neglected it has been by both the City and Columbia and how new community power is needed to make positive changes. " -Erutan Yoba, Organizer, Local 1199, Drug and Hospital Employees Union; Former employee, Harlem Hospital. " When Columbia came into Harlem in the early Sixties, we black physicians were promised by Columbia that we and our patients would have full access not only to a re- vitalized Harlem Hospital but to full opportunities for our- selves and our patients at Presbyterian, St. Lukes, and at all medical facilities in the Columbia'medical family. " However, these promises have not been kept, and black physicians are now demanding more'black power'or com- munity control over what is rightfully the community's, because false promises of integration in the general system have not been met... Furthermore, black physicians and the general community alike are outraged by the numerous cases of literal genocidal medical treatment and patient rejection because of narrow research interests in these institutions... " -Dr. Arthur Davidson. long time - member of Harlem and Delafield City Hospital staffs (recently censured by the Harlem - Colum- bia Hospital Board for his out- spoken criticism!) (11) Columbia P & S (From Page 11) in real institutional power in the Columbia empire may be what finally sent Dr. Trussell elsewhere - in fact, to Beth Israel, close to the very Bellevue territory he had pushed P & S to abandon!) But the P & S faculty distaste for real responsi- bility at Harlem continues - most recently in an unsuccessful attempt by certain faculty to prevent the rotation of any house staff from Presbyterian to Harlem. Some close ob- servers, including some supervising City officials and full time - Harlem medical staff people, are beginning to ask whether P & S, although it ingests more than $ 13 million a year for the Harlem affiliation, is really interested in developing an effective community hospital program. Meanwhile, the squeeze on educational and research financing becomes more severe, even as the Columbia and P & S public image are dented all the more. It was recently announced that the amount of project funding from the National Institutes of Health to P & S re- searchers is slated to be reduced about 10 percent this next year. It should be noted that, beneath the promotional imperial- ism and the patrician resistance there are some medical pro- fessionals, at least on the edges of the Columbia Presbyterian - empire, who are more committed to a new kind of service partnership with the community. Some staff physicians at Harlem Hospital favor a strong community board to push the development of a strong and responsive network of health and hospital services in Harlem, beginning with a new set of program priorities at the Hospital and the launching of convenient, comprehensive neighborhood health centers throughout the community. Columbia medical, nursing, and social work students part of the Student Health Organization, have been working with a group of Harlem parents concerned about school health problems. They have recently hustled a $ 43,000 grant for the parents group from the Ford Foundation - granted Columbia- Harlem community relations program (a 10 $ million nest egg for Columbia's 200 $ million endowment drive). (Just as the Rockefeller Foundation, along with others, is backing the Einstein Montefiore - empire to carry out its own brand of social buffering, if not social change, in the Bronx; so the Ford Foundation, particularly in the face of the community and campus siege of last spring, has poured social survival funding into Columbia. One skeptic has described the Ford grant to Columbia as: " a new concept in education - the land- lord is paid to study the tenants. ") Bulldozer Benefactor - St. Luke's Hospital, nestled beside the downtown Columbia College campus across the street from that disputed Colum- bia gymnasium site in Morningside Park - has developed some programs of outreach to community residents and pro- fessionals. While Columbia's urban renewal programs have been razing the buildings of " single room occupancy " where the lonely elderly and transiently lower income - persons often must dwell, St. Luke's has tried to develop some special pro- grams to reach these persons with medical service. The Riverside Health Center, a traditional City Health Department center recently converted into a comprehensive care unit, is operated by St. Luke's with Federal Office of Economic Oppor tunity funding with some degree of " community involve- ment " on an advisory council, at least for grievances. St. Luke's also operates an Office of Community Physician Rela- tions for continuing education and improved hospital access for West Side general practitioners, which has not reached. as many minority - group physicians as needed but has taken some important first steps. Some staff members from both St. Luke's and Roosevelt Hospitals are cooperating with the Planetarium Neighborhood Council in the development of a new City funded - neighborhood health center serving people between 74th and 86th Streets on the West Side. Such ef- forts certainly don't entirely countervail the generalized anger that both many community residents and physicians have about the exclusiveness of the private hospitals in the empire, but they are steps in a new, more generous direction. There is, however, irony in Morningside Heights, Inc. (of which St. Luke's is a member) moving occupants out, while a few medical evangelists from the same St. Luke's try to help them out. Those " downtown " Columbia students and faculty trying to " restructure " Columbia University to be more democratic and community responsible - " from within " are running. into an endless maze of powerless and confusing committees and study commissions, while the trustees, administrators, and established faculty with personal research publishing - baronies go churning on (see, e.g., " Columbia University: Still at the Crossroads, " by Elinor Langer, Science Magazine, November 22, 1968). The internal rumbles of discontent uptown at P & S -among the new breed of medical students; among the faculty, especially those in the " field " programs on the edges of the empire, more concerned about truly effective service programs in cooperation with the community; and even among the " academic workers " being organized by Local 1199 - are just beginning to be heard. Much more pressing have been the community organizations, the city politicians, and the hos- pital workers organizations demanding a new responsiveness from the old closed medical corporation. Beyond Inside Dopesters - All, however, share the dilemmas of the internal " restruc- terers " how do you grab hold of the seamy web that truly affects its total policies? Clearly, strategies simply of internal institutional insurgency - up through a baronial self selecting - medical faculty or a corporately self selecting - board of trustees -are overwhelming to consider at best. The most persuasive ways of re shaping - the policies of such an empire are obvi- ously to gain more control over the flow of public finance and the surrounding institutional turf. The education and research support game is increasingly a national one and national (and state) policy - now pretty much within the confines of the medical guild controlled - private market and their front financ- - ing insurance and reimbursement agents - shape the amount and content of even public financing of professional and institutional medical services. As the Harlem " Committee of 100 " have asserted, those community forces most concerned about excellent community service must have more direct leverage financing - and turf power - over the present medical empires. More direct public accountability must be expected for at least the business- service aspects of these closed corporations through both City and community government. They should, indeed, be con- sidered public institutions. Until then, Harlem - and everyone -can at best keep hats in hand and pray for a change of heart and cancer - and stroke. (12) The Retreat.. " Large hospitals, especially those associated with med- ical schools, have found that all levels of government- City, State and Federal have become increasingly concerned with how they function. As a result we are faced with an unprecedented number of new regulations, inspections, and ' audits '... The addition of such duties to our already overcrowded staff has extended it to its limit and further demands on its time are threatened by plans for the con- struction of other large institutions in northern Manhattan. In addition, the city ambulance system delivers increasing numbers of patients to our Admitting Emergency Depart- ment each year... All are determined to see our center through these turbulent times without for a moment low- ering the high standards which have always characterized our teaching, research and patient care. " -Milton R. Porter, M.D., President of the Medical Board, Presbyterian Hospital. " To meet recent changes in load and in community needs, the department has embarked upon an intensive study of its role in the care and understanding of the urban complex within which it operates. " -Dr. Stanley E. Bradley, Chairman, Department of Medicine, in 1967 Annual Report of Columbia - Pres- byterian Medical Center. "... the use of the term'community mental health centers'has unwittingly brought about confusion in the minds of our professional colleagues, potential patients and their families, and the general public... Indeed, there are some enthusiasts who, without scientific evidence, believe that social change will eradicate mental illness... only psychiatrists command the full depth of diagnostic knowledge and therapeutic skills... " -Dr. Lawrence Kolb, President, American Psychiatric Association; Chairman, Department of Psychi- try, Columbia College of Physicians & Surgeons (speaking in early October, 1968, shortly after an ad hoc committee of Washington Heights residents and pro- fessionals voted Dr. Kolb out of chairing a professional advisory meeting). " We should not decide the neighborhood's matters any more than they would want to decide our affairs for us... " -Dr. Andrew W. Cordier, Acting President, Columbia University, vs September, 1968. " One would like to believe that Columbia University had turned the corner and embarked on a new humane policy of cooperating with its neighbors. However, present indica- tions are that it is simply biding its time until the pressure dies down. There have been no signs of a commitment from the Administration to do anything for the community. It has not begun in any way to consult with the com- munity... Columbia continues to take the hard line at City Hall in defending its'right'to unlimited expansion and in negotiating for the urban renewal plan that suits its interests... Over 20 million dollars are at stake in the struggle over Columbia's community mental health center, and it contains the elements of an explosive issue bigger than the gym. " -From December, 1968 Newsletter of Alumni for a New Columbia. Community Resists Fordham Site Shift [EDITOR'S NOTE: The following article is reprinted with permission of Bronx Home News. It appeared in that local weekly November 15, 1968, under the headline, " Proposed Hospital Site Makes Community Sick. "] Should the community have a voice in where a hospital will be located? Approximately 150 Fordham area residents and a few pub- lic officials crowded into the auditorium of the nurses'resi- dence at Fordham Hospital last Wednesday night to explore the city's proposal to build a new Fordham Hospital in the vicinity of 180 St. and Third Ave. Voices were raised and tempers flared as residents accused Commissioner of Hospitals Joseph V. Terenzio and the city of proceeding with plans to relocate the hospital without the knowledge or consent of the community. Samuel Rubin, Chair- man of the Community Advisory Board of Fordham Hospital, who had called the meeting when he learned of the city's plan, had to exercise the voice of authority to keep order. In his opening remarks Mr. Rubin said that former Hospital Commissioner Trussell, without consultation, issued an order seven years ago to close Fordham Hospital. Mr. Rubin agreed that the hospital, which was built in 1904, is antiquated, but successfully argued that it should not be closed until provi- sions were made for replacement of its medical services and it remained open. Commissioner Terenzio said that there have been recently enacted changes in the State Hospital Code and a recent sur- vey of Fordham showed that it was one of the worst in meet- ing the State Code. It is not just a case of painting and fixing up but complete new facilities are necessary operating - rooms, lavatories, beds, wider corridors and everything else. The city wants a program and plan showing where they will be in 1975. Their present plan calls for a huge general hos- pital as a core, serviced by a circle of community health centers to take care of everyday illnesses and they have proposed that a new Fordham Hospital should be built near 180 St. as the core and eventually the present site of the hospital would be a health center.... Commissioner Terenzio offered the necessity of transporta- tion for personnel as well as patients as another reason for the choice and said it would be serviced by the Third Ave. El. When Councilman Aileen Ryan pointed out that the El will eventually be torn down, Terenzio conceded that it will but said there has been mention of rapid transit trains running on the existing Penn Central - tracks on Park Ave. His arguments went over like lead balloons with the audi- ence and one after another said that Fordham should remain at its present site and that the community should be entitled to have a say in the future of the hospital that has served them so well for so many years. When it was learned that a City Planning Board meeting was scheduled for Thursday, November 14, to decide the fate of the hospital, voices rose even louder because the meet- ing had not been publicized. The meeting ended with a resolution proposed that the November 14 meeting be postponed for 30 days to give the public time to learn about it, attend and have their say. (13) More on HSA De Centralization - [EDITOR'S NOTE: Continued from BULLETIN No. 5, questions about HEALTH - PAC community - controlled HSA decentralization proposal.] Wi What would happen to existing city wide - Health, Hos- pitals, and Community Mental Health Boards? They would probably shift more rapidly toward being gen- eral planning and standard - setting, essentially advisory, bodies to an increasingly integrated and decentralized Health Services Administration. A City comprehensive health planning agency, particularly one based primarily in neighborhood boards and with a neighborhood representative - city wide - board, would probably take on more prominence as the primary integrating force in overall policy development. There would undoubtedly be needed more special advisory committees and task forces to the HSA and more effective inter agency - councils and task forces within City government. Undoubtedly, all human ser- vices must be seen increasingly in a more total public frame- work emphasizing basic community development, as the early Model Cities efforts presage. Wi Will mental health and preventive public health pro- grams be diminished in such an integrated HSA approach? The program emphases on comprehensiveness of services, neighborhood convenience, social action, and citizen parti- cipation that should come from such decentralization and neighborhood empowering should live up to the best tradi- tions of community mental health and front - line preventive public health. Emphasis on consumer policy making - and the diverse health worker team based in the community should broaden considerably, not narrow, the " medical model " in these institutions and programs. Wi Will physicians cooperate? There is no reason for community service committed - phy- sicians to be insecure about greater community involvement. Their services will be more needed and prized than ever, as most experience with new neighborhood health centers has demonstrated. And where else can private institutions and professionals go if major public investment and the major public institutions are turned in this direction? In fact, there will undoubtedly be more opportunities for physicians in the public medical center setting with more balanced and compre- hensive neighborhood health programs. Some physician groups, some of them resentful of the exclusion of many physicians from City hospitals under affiliations, already have stated their support of the move toward neighborhood boards. Mi How can you make international research and teaching hospitals such as NYU Bellevue - into community hospitals? All hospitals and health centers should have access to and close relations with the biomedical scientific mainstream, as well as with the social and environmental sciences. Major medical research and teaching programs should be encour- aged as international as well as local social assets. On the other hand, we cannot tolerate the existence across the street from major open heart - surgery hospitals and down the alley from renowned micro biology - research centers of high infant mortality rates and overwhelming lead poisoning and respira- tory disease rates, just as we cannot allow the profit motive to fragment and to skew selectively the basic medical setting for all people. All areas must have hospitals and health cen- ters planned and organized first and foremost for the con- venience and protection of the people. Once this optimum service model is developed, vital research and teaching pro- grams should fit into this arrangement or at least not disrupt it. Total City Sell Out - of Health Step Closer THE NEWEST and perhaps ultimate City government fi- nancial and institutional plum sought by the private med- ical empires and voluntary hospital and insurance estab- lishment in their quest for private monopoly control over health services is emerging from the Mayor's Policy Plan- ning Council. This is to push permissive language into the City Charter (through the City Council) allowing the City to create a large front " corporation " for all City hospitals or to give away any or all Municipally - owned hospitals and health facilities as autonomous " corporations " under trusteeship, leaving them free to contract with a medical school or voluntary hospital for ALL their operations. Under the present Affiliation Plan covering City hospitals, the City contracts with such private institutions on a cost- plus basis for physician services, professional programs, and supervision of all teaching and research. Under the proposed " corporation " arrangements there would be no City Health Services Administration comprehensive respon- sibility and leadership or direct administration and staffing on the regional, neighborhood, or institutional level. There is no provision for selection of trustees for such corpora- tion (s) by the actual recipients of service nor any require- ment that they be representative of the communities most dependent on these institutions. Further, there is no pro- vision for neighborhood or regional health boards with public powers and community accountability to have juris- diction over comprehensive health services planning and operations to assure that all programs and institutions are publicly coordinated to meet community needs. Such cor- poration (s) thus would be only for particular facility frag- ments, further fracturing and making more unaccountable the pattern of health and hospital services. Such a quest for " permissive " City Charter language, formally being pushed by agents from the City Hospitals Department and the Budget Bureau for action early in 1969, is reminiscent of the political drive by private med- ical empires in the early 1960's. They then got new City Charter language (Amendment # 585b) to allow the City to: a.* enter into contracts with any university, med- ical school, or non profit - hospital... to provide and supervise.* . all or part of the professional and related staff in the operation of any institution or service under the jurisdiction of the [Hospitals] De- partment. The personnel so provided... shall not be deemed to be employees of the City of New York. " This opened the door wide to the omnibus Affiliation Plan that followed. (14)